Irma— Shirtless and handcuffed, the 17-year-old inmate stood in the hallway of the segregation unit, refusing to go into his room.

“You want to do something, do it now!” Kenyadi Evans snapped at two guards.

When a third guard arrived, Evans sized her up. “I’ll beat your ass, too,” he said.

Guard Jeff Butler had heard enough that chaotic night, one like so many other nights at the trouble-plagued Lincoln Hills School for Boys. He shoved the teen into the room and slammed the door, smashing his foot.

Out of frustration, Butler punched the metal door so hard that he broke his hand.

Before driving himself to the hospital, the four-year Lincoln Hills veteran sat in his truck and cried, prison records show.

Inside his room, Evans screamed and held up his foot so the staff could see the bleeding. The Milwaukee teen had lost parts of two small toes, but it would take prison officials nearly two hours to take him to a hospital 15 miles away.

He would eventually require multiple surgeries and the partial amputation of the two toes.

It was Nov. 29, 2015.

It had been 46 months — nearly four years — since a judge alerted Gov. Scott Walker that prison officials had waited hours to take an inmate who had been sexually assaulted to a hospital. Twelve months since the Department of Corrections had launched an internal investigation. Ten months since criminal investigators had opened their own probe. One month since prosecutors had told a court they believed children were being abused.

Six days after Evans’ toes were crushed, state agents descended on the facility, located 30 miles north of Wausau. The raid began to lay bare problems that would result in the departure of a dozen employees, spark an FBI investigation and deepen concerns about the state’s justice system for juveniles who commit serious crimes.

The night Evans was injured made clear that public officials — from front-line guards to the governor — had for years missed or ignored numerous warning signs about a facility descending into disorder.

On the way to the hospital, Evans boasted, said the guard who drove him there.

“He was talking about how much money he was going to make,” retired guard Doug Curtis recalled. “‘Boy, I’m going to make some money off of this. You’re going to pay.’”

Indeed, within a year taxpayers would give Evans a $300,000 settlement to avoid a lawsuit.

Problems fester

For years, officials knew or should have known about the thicket of problems at Lincoln Hills and its sister facility on the same campus, Copper Lake School for Girls.

“It all went on in plain view of the Department of Corrections, but nobody at the Department of Corrections knew how juvenile corrections worked or how Lincoln Hills operated or what was going on,” said Troy Bauch, who until recently was the union representative for workers there.

“Nobody cared.”

The sweeping criminal probe, now nearly 2 years old, is examining allegations of prisoner abuse, child neglect, sexual assault, intimidation of witnesses and victims, strangulation and tampering with public records. A separate internal investigation uncovered four incidents where inmates’ bones were broken.

The crisis at Lincoln Hills is rooted in systematic breakdowns, lax management, confusion over policies, a lack of communication and chronic staff shortages, a review of more than 1,000 pages of records and dozens of interviews by the Milwaukee Journal Sentinel found.

Officials trained staff improperly, failed to preserve video evidence, didn’t document serious incidents, and often shirked their duty to report matters to parents, police and social service agencies.

The shortcomings intensified in 2011 when the Walker administration shut down two youth prisons in southeastern Wisconsin to save $25 million a year. The move put all of the state’s serious teen offenders in one facility — hundreds of miles from most of their families.

“The entire climate went from mildly hellish to the ninth ring of hell,” said Timothy Johnson, a former guard.

While a developing crisis quickly became apparent, no one moved to address it.

After nearly six years in office, Walker has yet to visit Lincoln Hills.

A prison with an unassuming name

Opened in 1970, Lincoln Hills is surrounded by a chain-link fence topped with razor wire. Inmates live in dorm-style cottages that dot the campus near the small town of Irma. They attend school year-round in a central building.

The state tries to give the facility a different atmosphere than adult prisons. Inmates are referred to as youth, guards as youth counselors. Residents hang Halloween and Christmas decorations to try to give it a homey air.

Lincoln Hills generally holds inmates as young as 13 and as old as 25, separated by treatment and education needs. Most inmates are in their mid to late teens; some adults are being held for crimes they committed as juveniles.

About 145 boys are in Lincoln Hills and 20 girls in Copper Lake. The two areas are separated by fences. Holding an inmate costs more than $100,000 a year.

Most of the inmates are African-American and come from Milwaukee — 215 miles and 3½ hours away. The staff is largely white and from the rural north.

Unlike the state’s overpopulated adult prisons, there is plenty of room at Lincoln Hills. The prison was built to hold more than 500 inmates.

Typically, the inmates have committed serious, violent crimes — including homicide and robbery — or have had repeated run-ins with the law and didn’t turn their behavior around after being sent to group homes.

‘A caged dog’

The mother of one Milwaukee teen had mixed feelings when her son was sent to Lincoln Hills in 2014 at age 15. She worried about him being there but knew he needed serious intervention.

“(He) was at that point of no return,” said the mother, who spoke to the Journal Sentinel on the condition that her name not be used.

The boy was first arrested at 13 after breaking into a friend’s house. Before long, he broke into a school to try to steal computers. He ran away from group homes, once stealing a car.

At Lincoln Hills, he was frequently sent to segregation for beating others. Guards often doused him with pepper spray, his mother said.

“It felt like my son was a caged dog, not a child or a man,” she said.

In August, a staff member filed a report claiming the boy had attempted suicide by tying a shirt around his neck.

No one from Lincoln Hills notified the mother — a problem that repeatedly has cropped up at the juvenile prison.

She found out three months later, from a delinquency services official for Milwaukee County.

“When I got this letter, I almost had a heart attack,” she said. “My child tried to commit suicide and nobody told me? I would’ve walked, if I had to, up to Lincoln Hills and been there for him to find out what would make him want to harm himself.”

Her son, now 17, later said he had not attempted suicide but had covered his face with a shirt because he was about to be hit with pepper spray. She said she believed her son because he had never tried to hurt himself before.

A Department of Corrections spokesman said parents are notified only if an injury occurs.

When she contacted Lincoln Hills to find out why she hadn’t been told of the incident, she was told she would get a call back that day.

She is still waiting for that call.

Shutting down a prison

Numbers drove the decision to consolidate the state’s juvenile inmates at Lincoln Hills.

In 2004, the state’s youth prisons held 668 inmates on a typical day. By 2011, the figure had dropped to nearly half that.

The reduction, which mirrored national trends was due to several factors. Fewer juveniles were being arrested. When they did get in trouble, they were increasingly being placed in community-based settings instead of prisons.

It no longer made financial sense for the state to run three secure facilities — Lincoln Hills, Ethan Allen School in Waukesha County and Southern Oaks Girls School in Racine County. In 2010, Gov. Jim Doyle formed a task force to figure out what to do and concluded a juvenile prison should close.

Ethan Allen was older, its grounds were smaller and the facility was more expensive to run than Lincoln Hills. At the time they were closed, Ethan Allen and Southern Oaks together cost nearly $33 million a year to operate. Lincoln Hills cost about $19 million.

It was also easier to close Ethan Allen than Lincoln Hills. A state law requires a juvenile prison to be maintained in northern Wisconsin.

Former Republican state Sen. Clifford “Tiny” Krueger, a tavern keeper in Merrill who had performed in the circus because of his girth, inserted the measure into state law more than 40 years ago, recalled Jim Moeser, a former juvenile corrections official.

No such law applied to southeastern Wisconsin, even though most juvenile inmates come from the state’s most populated region.

Doyle’s task force said if a facility was to be closed, there should be careful planning for the transition.

When Walker took office in January 2011, he moved quickly to close Ethan Allen and Southern Oaks.

The consolidation saved $25 million a year. Like other changes the Republican governor made early in his tenure, the move was overshadowed by the mass protests spawned by Act 10, which weakened collective bargaining for most public employees.

As juvenile justice experts around the nation were recommending smaller, more localized facilities, Wisconsin went in the opposite direction, consolidating operations in a remote setting.

“This is a 19th century or early 20th century model, where you have a large state-operated facility hours away from the urban centers,” said Jeffrey Butts, director of a research center at John Jay College of Criminal Justice in New York.

“It is profoundly ineffective and wasteful.”

Rocky transition

More than 100 inmates were transferred to Lincoln Hills over several months in 2011, almost doubling the population.

Lincoln Hills got approval to bring on more than 100 new employees, but the institution was chronically short-staffed because of the challenge of hiring prison workers in a sparsely populated area. Supervisors forced employees to work double shifts, and living units were often operated with fewer employees, providing workers with less backup.

There were so many double shifts employees sometimes had trouble staying awake on their drives home, guards said.

“We got people walking around like zombies,” Curtis said in a recent interview as he reflected on his time as a guard there. “They want to know when they’re going to sleep again.”

The influx of new inmates created fights and arguments, as the teens sought to establish where they stood in the prison’s pecking order.

“I would come in at 6:30 and by 6:31 I’d have a couple guys on the floor in handcuffs,” said Johnson.

Guards, meanwhile, were angry because Act 10 made them pay more for their benefits, cutting a typical worker’s take-home pay by 8.5%. With the loss of collective bargaining, they also had less say in how the prison was run.

Around this time, prison officials instituted a philosophy that calls for using restraints less often and trying to talk inmates through their problems when they act up instead of isolating them. Guards were skeptical.

Paul Westerhaus, who for years played key roles in running Lincoln Hills, admitted to internal investigators in 2015 that he didn’t recognize the scope of the problems that were developing or move to fix them. The abrupt consolidation threw the staff into disarray, and the institution didn’t have a solid training program to deal with it, he said.

He also attributed the problems to an inmate population that had more mental health issues and was increasingly aggressive. Having one facility made it tougher to separate inmates who clashed because they couldn’t be transferred to another prison.

“It’s almost like it began a perfect storm, and it just sort of went and grew from there,” he said.

Warnings arrived early

In February 2012, Racine County Circuit Judge Richard Kreul did something he’d never done during 18 years on the bench. He wrote the governor a letter about one of his cases.

“I’m sure reading the attached memo will shock you as much as it did me,” he wrote.

The memo Kreul sent to Walker described an incident in which an inmate from Racine was forced to perform oral sex on his roommate and then beaten unconscious.

Workers learned of the assault at 4 p.m. They didn’t get the victim medical treatment for three hours.

The delay happened in part because other inmates were playing a basketball game, according to a Racine County human services report.

“What did you want us to do, stop the game?” Lincoln Hills psychologist Paul Hesse asked with a chuckle when a Racine County official inquired about the sexual assault and beating, according to county records.

That night, more than six hours after the assault was discovered, hospital workers — not prison staff — reported the assault to the Lincoln County Sheriff’s Department. The offender was ultimately convicted of the beating and sexual assault.

Racine County officials were tipped to the assault by another youth, but only got details from Lincoln Hills officials after making repeated inquiries. In response, Racine County dramatically scaled back sending juveniles to Lincoln Hills.

The day after the assault, Lincoln Hills officials sent the victim to segregated housing for disruptive behavior. It was that detail — punishing the victim — that prompted the judge to write the governor eight months after Ethan Allen School was consolidated into Lincoln Hills.

His memo was addressed to the governor, but Walker’s aides said they never showed it to him. At the time, he was fighting for his political life during a recall election sparked by Act 10.

No one was disciplined for the handling of the assault. Department of Corrections officials told county workers they were retraining employees, but they did not get back to the judge himself.

“Zero,” said Kreul, who is now retired. “I got nothing back. I would not have sent the letter if I thought it was going to go to the circular file. … I thought somebody would say, ‘This merits some real investigation.'”

At the time of the sexual assault and delayed response, Westerhaus was the prison’s superintendent and John Ourada its deputy superintendent.

Walker’s team promoted the pair two years later, in 2014.

Red flags reach Milwaukee

Warning signs went up in Milwaukee County in the fall of 2014.

Robin Dorman, the public defender in charge of the Milwaukee office, discovered one of her clients wasn’t being sent to class or receiving treatment at Lincoln Hills. She soon learned that inmate wasn’t the only one.

“To me, it was a complete breach of trust,” she said. “It’s called Lincoln Hills School, and our kids weren’t receiving an education.”

Dorman alerted Children’s Court Judge Mary Triggiano and Tom Wanta, who was in charge of delinquency services for Milwaukee County.

Dorman soon found out about allegations of abuse, fights and using segregation even when a psychologist recommended against it.

“Management is aware of all of these problems. Typically, when management becomes aware of a problem, the problem just gets worse,” one of Dorman’s colleagues wrote in a memo.

Dorman passed that memo onto Milwaukee County Chief Deputy District Attorney Kent Lovern, who forwarded it to the Department of Corrections.

The department launched an investigation but hit a snag because Dorman said she couldn’t provide more details, citing confidentiality rules. Internal investigators said they couldn’t move as fast as they would have liked because they didn’t have names or dates.

Nevertheless, corrections officials were soon convinced crimes by staff had occurred at Lincoln Hills. In January 2015, aides to Attorney General Brad Schimel agreed to launch a criminal probe.

Seven months later, Corrections Secretary Ed Wall got a personal alert that problems were continuing. On a visit to Lincoln Hills, teens thronged around him in the library.

“They’re torturing us,” they told Wall.

“Numb about the whole situation”

On every one of his shifts as a guard, Johnson would sharpen his 911 knife — a fishhook-shaped device workers use to cut ligatures if inmates attempt to choke or hang themselves. He used it so much it would quickly dull.

“There were so many suicide attempts on the girls’ side that you would lose track,” Johnson said in an interview with the Journal Sentinel. “One girl would hang herself, all the sudden you’d have four or five copycats.”

It wasn’t just suicide attempts. Inmates would harm themselves in other ways, cutting themselves with anything they could find and sometimes jamming pencils or plastic silverware into their wounds to make them worse.

“To work in a place like that and deal with so many tragedies, you do become sort of numb about the whole situation,” Johnson said.

Johnson quit in January amid an investigation into inmates being injured. He contends he did nothing wrong.

Oct. 1, 2015, was a tense night in one of the cottages at Copper Lake. The workers weren’t getting along, and the inmates were screaming at each other.

Guard Lisa Brener turned on a large fan to drown out the arguments and try to calm the girls to sleep. Some complained they were cold.

One 15-year-old girl said if the fan stayed on, she was going to “tie off” — slang for hanging or choking herself. Guard Scott McKenna saw on a camera that the girl, who was in Copper Lake for robbery, had covered herself with a blanket.

With a supervisor’s permission, he went in the room and took the blanket to make sure she wouldn’t hurt herself under it.

Five minutes later, she was covered with a mattress. This time, McKenna didn’t ask permission to go into her room.

“You’re not my daddy,” she screamed when he walked in. “You can’t tell me what to do.”

The girl stood up suddenly. McKenna, who is almost a foot taller, pushed her against the wall with his hand on her neck, the girl and two guards later told investigators. The girl looked petrified but didn’t say a word, Brener said.

McKenna told investigators his hand was just below the girl’s neck, on her clavicle.

McKenna threw her mattress into the hall. As the girl came up to him, he pushed her back with his forearm, according to investigators’ reports.

The girl’s mother learned of the matter from the girl and a social worker, the mother said.

“I don’t want anybody putting hands on my kids, especially ones who are supposed to be protecting them,” she said.

The next day, McKenna was put on paid leave. He stood by his decision to go into the girl’s room to get the mattress even though he didn’t have permission.

“I would rather be explaining this than why a kid is dead,” McKenna told internal investigators.

The Lincoln County Sheriff’s Department recommended District Attorney Don Dunphy charge McKenna with child abuse and strangulation. Dunphy consulted with Schimel’s office, but more than a year later has not pressed charges. Dunphy said he hasn’t been kept up to date on the matter since the FBI took over the overall investigation of Lincoln Hills.

The Department of Corrections fired McKenna but reversed course and allowed him to quit.

In a settlement with the state, McKenna is banned from seeking employment with the Department of Corrections again. Under the deal, he also got $6,000 from taxpayers.

Improper training

Assaults at the prison often were linked to poor training — including by Lincoln Hills’ use-of-force expert.

For 10 years, Dusty Meunier was the lead trainer at Lincoln Hills, but he trained staff improperly, investigators found. Security Director Bruce Sunde and Meunier’s other bosses either didn’t notice or didn’t do anything to stop him.

In teaching workers how to break up fights, Meunier showed a video of a guard putting his knee in the back of a young inmate — without telling them the technique was improper and could cause suffocation or death. Investigators later found the knee-to-back move was routinely used by staff.

Meunier was supposed to emphasize to workers that they needed to be careful when handling juveniles because their bones could break more easily than those of adults. He didn’t do that.

Meunier didn’t contact nurses when inmates were injured. He changed techniques for securing inmates without getting permission from his superiors. He reviewed incidents that appeared abusive but deemed them appropriate. He didn’t require staff to file reports documenting when they used force despite policies that require them.

Meunier himself was ultimately found to have violated work rules in 16 incidents between 2013 and 2015. He was fired in May 2016.

In one July 2015 incident, Meunier led a group of guards as two of them blasted a dorm room with pepper spray after an inmate barricaded himself inside.

The cloud of pepper spray was so thick that it drove several staff members from the area. Meunier told the inmate to lay on the floor when he was ready to be removed. Staff took his roommate out but left the inmate inside on the floor.

He was left in the room with no one watching for almost six minutes. When the guards returned, they had him crawl into the hall because the pepper spray was so thick in the air they didn’t want to enter the room.

A review conducted months later concluded the incident was “abusive since it appears (the boy) was intentionally left in the room for this period of time and that (he) was willing to cooperate with staff.”

Retirements followed by raid

The Justice Department investigation had been going on for almost a year when Evans’ foot was mangled in the door. Two agents were on it, but only worked it part time.

Asked if more resources should have been dedicated to the investigation early on, Schimel said, “Yeah. Hindsight’s 20/20.”

The pace of the investigation picked up when Evans was hurt. Within days, state Department of Justice agents began seizing video from the institution’s recorders.

Prison leaders didn’t know what was going on.

“What is this all about?!?” Deputy Superintendent Wendy Peterson wrote Ourada, the superintendent, in a Dec. 2, 2015, email when she learned of the Justice Department visit.

For more than 15 years, Ourada and juvenile corrections director Westerhaus had integral roles in running Lincoln Hills. Now they were left out of the loop — and wouldn’t get back in.

“Not sure what this is about,” Westerhaus emailed Ourada and Peterson when they learned guards from adult prisons would be brought in to monitor Evans, instead of Lincoln Hills staff.

Westerhaus and Ourada earlier had announced they would retire. But they abruptly moved up that timetable, retiring within days of Evans’ foot being crushed.

They received their full benefits and were granted special permission to immediately cash out their unused leave time, with Westerhaus receiving $35,000 and Ourada $66,000.

Two days after they cleared out their offices, about 50 state law enforcement agents and attorneys descended on Lincoln Hills. Within weeks, they would hand the investigation over to the FBI.

Agents cut off the phone lines and told workers coming off their shifts that Saturday morning that they could not leave.

Prison staff members aren’t supposed to bring cellphones into the institution, but some did. They called and texted friends and family to tell them what was going on.

The agents interviewed workers and remained on site for weeks to talk to about 250 inmates. Eventually, they would conduct hundreds of hours of interviews.

Even as the raid unfolded, calamity flared in the prison. Hours after agents arrived, staff at Copper Lake found a 15-year-old inmate unconscious. The girl had taken pills and tried to hang herself.

The raid and the incident that led to it blindsided Milwaukee County officials, who had been given assurances by the Department of Corrections that their concerns were being addressed.

“We were tired of getting surprised,” said Triggiano, the children’s court judge.

Butler and another guard who had been on the scene when Evans’ toes were smashed were put on paid leave. Butler quit within days.

The following week, chief psychologist Vincent Ramos was fired for having taken pictures of interns in a hotel room while wearing only his underwear and a T-shirt. He had been investigated — but not disciplined — months earlier for commenting that a teenage inmate’s breasts looked “rode hard and put away wet.”

Since November 2014, eight employees have been fired and 14 have resigned or retired amid internal investigations. Some of those departures are not related to the initial abuse allegations, according to the Department of Corrections.

Walker replaced Corrections Secretary Wall with Jon Litscher, who had run the department a dozen years earlier. Litscher promoted Peterson to superintendent, but new people were put in place in the top ranks of the prison and the department’s central office.

In response to the problems, Department of Corrections officials installed 60 more surveillance cameras and equipped guards with body cameras. They began holding weekly meetings to review major incidents. They dramatically increased training.

To help combat the staffing shortage, Litscher raised entry-level wages by 80 cents, to $16 an hour. The pay increase was seen as a welcome starting point by staff who had their take-home wages cut as part of Act 10. This year, the state has hired more than 40 new guards at Lincoln Hills.

In November, the prison ended a decades-long practice of having guards dispense medication. Those duties were handed over to nurses after guards accidentally gave inmates the wrong prescription drugs several times.

“The dynamic is 100% better,” Department of Correction spokesman Tristan Cook said of changes that have been adopted in the last year.

But the chief judge of Milwaukee County, Maxine White, said her confidence in how Lincoln Hills is run has yet to be restored. After she visited Lincoln Hills in January, she called the facility inhumane.

“I saw a detention facility,” she said in a recent interview, noting state law emphasizes the importance of rehabilitating juvenile delinquents.

“They were in their rooms. Nothing was going on. There was no activity. Nothing. For $300 a day, we were getting housing. But in the juvenile code, that’s not the deal.”

This month, Walker told Milwaukee County officials he is open to having the state help pay for building a local 36-bed juvenile corrections center to help it limit how many kids it sends to Lincoln Hills.

The idea is still in the early stages, and it’s unclear if lawmakers will sign onto the plan.

Quiet federal probe

The internal investigation of Lincoln Hills was completed in the spring of 2016, but criminal and civil investigations remain open. The FBI hasn’t visited the prison for nearly a year.

“People would be sorely mistaken if they thought we were not continuing this investigation,” said John Vaudreuil, the U.S. attorney for Wisconsin’s western district.

The case is taking so long because it is complex, he said. Agents are using a computer program to link incidents mentioned by inmates in hundreds of interviews, he said.

Separately, the U.S. Department of Justice’s Civil Rights Division is reviewing whether there was a pattern of civil rights violations at Lincoln Hills.

If the department makes such a finding, the federal government could sue the state and force changes under the watch of a judge — an expensive endeavor that has compelled other states to reform their juvenile justice systems.

Meanwhile, juveniles continue to be sent to Lincoln Hills and Copper Lake. Local officials have few other options for serious offenders.

For judges in Milwaukee County Children’s Court, who handle child welfare and juvenile delinquency cases, they face the quandary of sending youth to a place they view as dangerous.

“Day in and day out, my colleagues are asked to remove children from homes, parental homes, that are being investigated for abuse and neglect,” said Triggiano. “In the same breath, we are being asked to send kids to a place being investigated for abuse and neglect.”

Victim becomes suspect

Soon after Evans’ toes were crushed at Lincoln Hills, he attacked an inmate at a Wauwatosa detention center. He was convicted of battery in June.

Evans, who turned 18 in September, has been acting out, sometimes violently, since middle school, court records show. He ran away from group homes, assaulted a teacher and stole a van before he was sent to Lincoln Hills on a theft charge. There, he often was in the segregation unit for fighting.

By this fall, his circumstances appeared to have improved. On Sept. 20, Evans signed the settlement that would provide him $300,000.

Three days later, before he got the settlement money, Evans and two others snatched a woman’s car keys from a table at a McDonald’s in Milwaukee, ran into the parking lot and stole her Honda Odyssey, prosecutors allege.

Records show Evans is a suspect in four other carjacking and car theft cases from October. Prosecutors will decide soon whether to charge him, said Assistant District Attorney Benjamin Wesson.

Evans is the first former inmate to get a settlement, but he may not be the last. The Walker administration has hired a law firm specifically to handle expected lawsuits against the state from former Lincoln Hills inmates and their families.

John Diedrich of the Journal Sentinel staff contributed to this report.